[Senate Hearing 113-897]
[From the U.S. Government Publishing Office]
S. Hrg. 113-897
MEDICARE ADVANTAGE: CHANGING
NETWORKS AND EFFECTS ON CONSUMERS
=======================================================================
HEARING
BEFORE THE
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
HARTFORD, CONNECTICUT
__________
JANUARY 22, 2014
__________
Serial No. 113-17
Printed for the use of the Special Committee on Aging
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
46-922 PDF WASHINGTON : 2023
SPECIAL COMMITTEE ON AGING
BILL NELSON, Florida, Chairman
RON WYDEN, Oregon SUSAN M. COLLINS, Maine
ROBERT P. CASEY, JR., Pennsylvania BOB CORKER, Tennessee
CLAIRE McCASKILL, Missouri ORRIN G. HATCH, Utah
SHELDON WHITEHOUSE, Rhode Island MARK KIRK, Illinois
KIRSTEN E. GILLIBRAND, New York DEAN HELLER, Nevada
JOE MANCHIN III West Virginia JEFF FLAKE, Arizona
RICHARD BLUMENTHAL, Connecticut KELLY AYOTTE, New Hampshire
TAMMY BALDWIN, Wisconsin TIM SCOTT, South Carolina
JOE DONNELLY, Indiana TED CRUZ, Texas
ELIZABETH WARREN, Massachusetts
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Kim Lipsky, Majority Staff Director
Priscilla Hanley, Minority Staff Director
C O N T E N T S
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Page
Opening Statement of Senator Richard Blumenthal, Member of the
Committee...................................................... 1
Opening Statement of Senator Sheldon Whitehouse, Member of the
Committee...................................................... 2
PANEL OF WITNESSES
Stephanie Kanwit, Principal, Kanwit Healthcare Consulting, and
Former Special Counsel, America's Health Insurance Plans....... 4
Brian Biles, M.D., Professor, George Washington University School
of Public Health and Health Services and Chair of the
Department of Health Services Management and Policy............ 6
Judith Stein, Esq., Founder and Executive Director of the Center
for Medicare Advocacy.......................................... 9
Michael Saffir, M.D., Physiatrist and President, Connecticut
State Medical Society.......................................... 13
Raymond Welch, M.D., Dermatologist, Rhode Island Dermatology and
Laser Medicine................................................. 15
APPENDIX
Prepared Witness Statements
Stephanie Kanwit, Principal, Kanwit Healthcare Consulting, and
Former Special Counsel, America's Health Insurance Plans....... 37
Brian Biles, M.D., Professor, George Washington University School
of Public Health and Health Services and Chair of the
Department of Health Services Management and Policy............ 51
Judith Stein, Esq., Executive Director, Center for Medicare
Advocacy....................................................... 58
Michael Saffir, M.D., Physiatrist and President, Connecticut
State Medical Society.......................................... 63
Raymond Welch, M.D., Dermatologist, Rhode Island Dermatology and
Laser Medicine................................................. 67
Statements for the Record
George C. Jepsen, Attorney General, State of Connecticut......... 73
Alan F. List, M.D., President and CEO, Frank and Carol Morsani
Chair, Moffitt Cancer Center................................... 75
Robert Buccieri, Medicare Beneficiary............................ 77
MEDICARE ADVANTAGE: CHANGING
NETWORKS AND EFFECTS ON CONSUMERS
----------
WEDNESDAY, JANUARY 22, 2014
U.S. Senate,
Special Committee on Aging,
Washington, DC.
The Committee met, pursuant to notice, at 2:00 p.m., Room
2E, Legislative Office Building, 300 Capitol Avenue, Hartford,
Connecticut, Hon. Richard Blumenthal, Member of the Committee,
presiding.
Present: Senators Blumenthal and Whitehouse.
Also present: Senator Murphy.
OPENING STATEMENT OF SENATOR
RICHARD BLUMENTHAL, MEMBER OF THE COMMITTEE
Senator Blumenthal. Thank you everyone for being here.
For those who may not have been outside and for the record,
I want to thank Chairman Nelson of the Special Committee on
Aging. I serve on it, and he has given us permission to be here
today and to have this field hearing on a topic that I know is
very, very important to the State of Connecticut and to the
State of Rhode Island.
I want to welcome my colleague, Senator Murphy and Senator
Sheldon Whitehouse of Rhode Island.
We have a panel of five really outstanding witnesses today,
and I want to welcome them all here, especially those who made
it to Hartford from Washington and Rhode Island.
We think it is important to hold this hearing for a number
of reasons. While we are seeing insurers decide to offer
narrower networks, in an intent to reduce costs across the
country, these decisions have a very dramatic impact here in
Connecticut, where 2,250 providers were terminated with
virtually no notice, and that termination affected about 61,000
patients under the Medicare Advantage program, about 43 percent
of all the patients who have Medicare Advantage plans.
We are here today to hear from the folks who can shed some
light on what these sudden terminations mean for patients, in
the midst of deciding whether they stay with their Medicare
Advantage plans, and what options are available to them and
what can be done to prevent this kind of abusive and, very
likely, illegal action from happening again.
Right now, the terminations have been enjoined. There will
be an appellate argument next week.
I have joined in that argument as a friend of the court in
a brief that I filed because I feel so strongly, as do my
colleagues, about the importance of this issue to people in
Connecticut and people throughout the country.
I do not know whether Senator Murphy or Senator Whitehouse
have any additional statements that they would like to make.
Senator Whitehouse?
OPENING STATEMENT OF SENATOR
SHELDON WHITEHOUSE, MEMBER OF THE COMMITTEE
Senator Whitehouse. No. I just want to thank you both for
your hospitality. It is good to be here in your state. Rhode
Island, your eastern neighbor, has the same predicament with
United.
I am pleased to serve on the Aging Committee with Senator
Blumenthal and on the Health, Education, Labor and Pensions
Committee with Senator Murphy, and since both of those
committees have a keen interest in this issue, it is a delight
to be here.
They are also terrific colleagues, and, on this issue,
people talk about Washington and who is a showhorse and who is
a workhorse. You have two workhorses in the Connecticut Senate
on health care issues, so it is a great honor for me to be here
with both of them.
Senator Blumenthal. Thank you.
Senator Murphy?
Senator Murphy. Thank you, Senator Blumenthal.
I just wanted to thank you for allowing me, as a non-Aging
Committee member, to sit in on this hearing, but, as a member
of the Health, Education, Labor and Pensions Committee, this is
obviously an issue that we have jurisdiction over as well, so,
really excited to be here.
This is a great panel, and I think what I hope that we will
do here today is to examine both the immediate issue, which is
of concern to thousands of Connecticut and Rhode Island
residents, but also talk about the bigger picture because we do
live in a world in which we are going to see the contraction
and sometimes expansion, but certainly always change, in
provider networks, and we have just got to sit together and
figure out the best way to do that from a cost perspective,
from a patient protection perspective and from a quality
perspective.
Senator Blumenthal. I should say that both Senator Murphy
and Senator Whitehouse, along with myself, are members of a
task force on health care delivery, which we have organized to
look at these issues.
Sheldon Whitehouse has been an advocate on these issues
from well before I was in the Senate, and I want to thank him
particularly for his leadership.
Let me introduce the witnesses that we have here today,
with the first panel before us.
Stephanie Kanwit is a Senior Health Care Consultant in
Washington, DC, who currently serves as Special Counsel to
America's Health Insurance Plans, AHIP, and the Pharmaceutical
Care Management Association.
Prior to that, she served as General Counsel for AHIP and
three stints as a partner in private law firms in DC and
Chicago--Chadwell and Kayser, Lamet Kanwit and Davis in
Chicago, Epstein Becker and Green in Washington, and she also
has served as Vice President of Health Litigation at Aetna here
in Hartford.
Brian Biles comes to us from George Washington University
School of Public Health and Health Service, where he is
professor and Chair of the Department of Health Services
Management and Policy.
Prior to his current position, he was Senior Vice President
of the Commonwealth Fund and served for seven years as Staff
Director of the Subcommittee on Health in the Committee on Ways
and Means of the United States House of Representatives. He
worked on the Health Subcommittees chaired by Representative
Henry Waxman and Senator Edward Kennedy, two great heroes in
health care advocacy, and he has authored numerous papers. I am
not going to go through the entire list, but he has a master's
degree in public health from Johns Hopkins University, and he
received his doctor of medicine and bachelor of arts degrees
with honors from the University of Kansas.
I am told--I hope, reliably--that your wife is from
Connecticut.
Judith Stein, another hero, is the founder and Executive
Director of the Center for Medicare Advocacy.
Anybody who has been in this building, anybody who has any
experience in health care in Connecticut knows of her extensive
experience in developing and administering Medicare advocacy
projects. She has been a champion of Medicare beneficiaries,
producing educational materials, teaching and consulting.
She has been the lead counsel or co-counsel in numerous
Federal class action and individual cases, challenging improper
Medicare policies and denials, and I have been privileged to
join with her when I served as attorney general in some of
those actions.
She also was a delegate to the 2005 White House Conference
on Aging and received the Connecticut Commission on Aging
Agewise Advocate Award in 2007.
She graduated cum laude from Williams College and received
her law degree with honors from Catholic University School of
Law.
Dr. Michael Saffir is a practicing psychiatrist,
specializing in physical medicine, rehabilitation and pain
management. He practices at the Orthopedic Specialty group in
Fairfield, Connecticut and is the Division Chief of Medicine
and Rehabilitation in the Department of Medicine at St.
Vincent's Medical Center in Bridgeport. He is also President of
the Connecticut State Medical Society.
Did I get your specialty wrong?
Dr. Saffir. Physiatrist. Physical medicine rehabilitation.
Senator Blumenthal. Okay. Thank you.
I am going to ask Senator Whitehouse to introduce Dr.
Welch, who is from Rhode Island.
Senator Whitehouse. It is my great honor to have the
opportunity to introduce Dr. Raymond Welch, who is a practicing
physician in Rhode Island in the field of dermatology. He has
been practicing in the Providence area for 28 years, focusing
his work on the diagnosis and treatment of skin cancer. He is
also an Assistant Clinical Professor at the Warren Alpert
School of Medicine at Brown University.
He has a long record of recognitions. He was elected in
2007 to the Noah Worcester Dermatological Society. He is a
member of the New England Dermatology Society, the Rhode Island
Dermatology Society and the American Society of Laser Medicine
and Surgery.
He is a graduate of Albany Medical College in New York,
served his residency at Albany Medical Center Hospital and
completed his dermatology residence at Duke University Medical
Center.
We are delighted that he took the trouble to come from
Rhode Island to be here and to share his perspective.
Thank you very much.
Senator Blumenthal. Thank you.
Why don't we----
Senator Whitehouse. Should we get into the record now about
United and whether their being here or not here, they were at
least invited?
Senator Blumenthal. Sheldon Whitehouse, Senator Whitehouse,
makes the excellent point that I want to put on the record that
UnitedHealthcare Group was invited. I did invite them to this
hearing. They have declined to appear.
Why don't we begin going from my left to right?
We will begin with you, Ms. Kanwit.
STATEMENT OF STEPHANIE KANWIT, PRINCIPAL,
KANWIT HEALTHCARE CONSULTING, AND FORMER
SPECIAL COUNSEL, AMERICA'S HEALTH INSURANCE PLANS
Ms. Kanwit. Thank you. Good afternoon, Chairman Blumenthal
and members of the Committee.
I am honored to be here in my home State of Connecticut. I
am Stephanie Kanwit, and I am testifying today on behalf of
America's Health Insurance Plans, known as AHIP.
I appreciate this opportunity to testify on issues
surrounding provider networks in the Medicare Advantage Program
and the strategies our members are employing in this area to
hold down costs and, at the same time, improve value for their
enrollees.
Health plans in the Medicare Advantage, MA, program have a
strong track record of offering high-quality coverage options
with innovative programs and services for both seniors and
individuals with disabilities. As emphasized in our written
testimony, one strategy that plans are pioneering involves the
use of high-value provider networks along with programs that
encourage enrollees to obtain care from providers who have
demonstrated, based on performance, metrics, their ability to
deliver high-quality and cost-effective care, and those are the
keys.
Our written testimony focuses on three broad areas:
First, background on the MA program, including the value it
delivers to beneficiaries.
Second, as the MA program faces a future of severe
underfunding, we discuss the opportunity for these high-value
provider networks I mentioned to preserve benefits and mitigate
the cost impact on the MA beneficiaries.
Third, we focus on the leadership role that health plans
are playing in advancing delivery system reforms, so, just some
quick background. More than 14.5 million seniors in the United
States and people with disabilities, about 28 percent of the
Medicare population, currently are enrolled in MA plans.
Senator Whitehouse, that is higher in Rhode Island. It is
about 35 percent.
Why? They value the care coordination and disease
management activities, improved quality of care and innovative
services and benefits that are available through these plans.
Now MA plans offer a different approach to health care
delivery than beneficiaries experience under the regular
Medicare fee-for-service, FFS, program. They have developed
systems of coordinated care--key word, coordinated--for
ensuring that beneficiaries receive health care services on a
timely basis while also emphasizing prevention and providing
access to disease management services for chronic conditions.
These coordinated services and systems provide for the seamless
delivery of health care across the continuum.
We are talking physician services, hospital care,
prescription drugs and other health care services, all
integrated and delivered through an organized system. The
overriding purpose is to prevent illness, manage chronic
conditions, improve health status and swiftly treat medical
conditions as they occur rather than waiting until they have
advanced to a more serious state.
The key question is this: Have they been successful?
The answer is yes.
First, we know that because survey findings show that MA
enrollees are highly, highly satisfied with their health
plans--90 percent, plus.
Secondly, we know that because research findings
consistently demonstrate that MA plans have better health
outcomes and beneficiaries receive higher-quality care than
their counterparts in the Medicare FFS program.
The value that MA enrollees receive through their plans can
also be seen in the additional services and benefits that are
offered--services and benefits that are not offered in the
Medicare fee-for-service program. Although these vary from plan
to plan, these typically include case management, disease
management, wellness and prevention programs, prescription drug
management tools, nurse help hotlines, and vision, hearing and
dental benefits.
MA plans also protect beneficiaries from high out-of-pocket
costs, and this year, in 2014, all MA plans are going to offer
an out-of-pocket maximum for beneficiary costs.
Another important feature of MA programs is enrollees have
strong consumer protections, and this includes extensive
network adequacy standards, which ensure that MA enrollees have
access to all provider types, including primary care physician
as well as specialists within a reasonable time and distance
from their homes.
CMS works with MA plans when network changes are made to
ensure that beneficiaries continue to have access to the
benefits and services they need, but we are deeply concerned
that the MA program is facing a future of severe underfunding
that jeopardizes the stability of these plans.
The Affordable Care Act, the health reform law, ACA,
imposes more than $200 billion in funding cuts on MA over a 10-
year program. Through last month, December of 2013, only 10
percent of those cuts had gone into effect, but another 35
percent will be phased in between 2014 and 2016, so they are
back-loaded.
On top of those cuts, MA enrollees are impacted by the new
ACA health insurance tax that went into effect on January 1st,
2014.
Now facing such a challenging budgetary environment, MA
plans are working hard to maintain access to high-value
benefits and services for their enrollees, but we have serious
concerns, as I mentioned, about the underfunding of the MA
program as ACA cuts are phased in at an increasingly faster
rate over the next several years.
The need is greater now than ever before for innovations
that deliver increased values to beneficiaries with
increasingly limited resources that are available to support
the MA program.
In response to that challenge, MA plans are working hard to
preserve benefits and improve quality for enrollees by
developing what I mentioned previously--high-value provider
networks.
What are high-value provider networks?
Health plans typically develop these networks using
performance metrics, with a strong emphasis on quality
criteria, to select high-performing, cost-effective providers,
using widely recognized, evidence-based measures of provider
performance such as those endorsed by the National Quality
Forum. Health plans can create select or tiered networks of
providers comprised of clinicians and facilities that score
well on measures of efficiency and quality.
Now a central goal of these high-value provider networks,
including those offered by MA plans, is to improve health care
quality and efficiency through ongoing evaluation of provider
performance, assessment of resource use, referrals to other
high-performing providers and the exchange of health
information with the plan and other providers caring for the
same patients; so, that kind of coordination.
Critically, these high-value provider networks create
strong incentives for providers to offer competitive prices in
response to the increased number of patients they gain as a
member of the network, and this, in turn, enables the health
plans to deliver substantial savings to their enrollees in
addition to connecting them to high-quality providers.
I want to thank you for considering our views on these
important issues.
We look forward to working with Congress to strengthen and
preserve the MA program, and, to achieve this goal, we urge you
to help ensure that funding for the MA program is stabilized
and that MA plans have the flexibility to advance high-value
provider networks and other innovations that promote quality
and efficiency for Medicare beneficiaries.
Thank you.
Senator Blumenthal. Thank you very much.
Professor.
STATEMENT OF BRIAN BILES, M.D., PROFESSOR, GEORGE
WASHINGTON UNIVERSITY SCHOOL OF PUBLIC HEALTH AND
HEALTH SERVICES AND CHAIR OF THE DEPARTMENT OF
HEALTH SERVICES MANAGEMENT AND POLICY
Dr. Biles. Thank you very much, Senator Blumenthal, Senator
Whitehouse, Senator Murphy, for convening this hearing on what
is really a new and very important issue.
I would note that my wife, in fact, did grow up in Easton,
where her great grandparents moved from Slovakia in the 1880s
to take over some of the farmland in that area.
Senator Blumenthal. Not a lot of farmland left in Easton.
Dr. Biles. Not a lot. It is all--as you well know Easton.
The focus of this hearing--I think, it could be termed
network narrowing of physicians by UnitedHealthcare's Medicare
Advantage plans--is important now both in Connecticut and Rhode
Island, and nationwide, and it is certainly to become more
important in the years ahead, which I think is why this is such
an important discussion. New Medicare policies to address the
situation will be important, particularly to elderly and
disabled beneficiaries.
The focus of today's hearing is United Healthcare's recent
action, and a special concern regarding United's announcement
is when it occurred and particularly occurred after the
beginning of the Medicare beneficiary open enrollment period
that began on October 15th and ran until December 7th.
I think if I were to focus on one area it is the lack of
advance notice. I do not know whether it is too strong to say
this is an example of bait and switch, but clearly, elderly,
disabled beneficiaries went through an open enrollment period
before all of this was clearly understood and they could take
action in response.
The term, network narrowing, has been described as
reduction in the number of physicians participating in managed
care plans, and I will focus today in five areas.
First, the point is that Medicare beneficiaries always have
the option to be covered by traditional Medicare, which has the
broadest network, of course, of any health plan and any health
insurance program the country.
Second, again, the managed care network narrowing that we
see in Connecticut is neither new nor limited to Medicare.
Three, Medicare--and this is a particularly important
issue--has been paying private plans more than it costs in
traditional Medicare fee-for-service for beneficiaries enrolled
in the plan. Our research found that extra payments--payments
in addition to costs in Medicare, traditional Medicare--in 2009
averaged 14 percent, $1,100 per enrollee and a total of over
$12 billion.
Fourth, as payments are reduced, the plans with policies
have been mentioned in the ACA. To reduce these extra
overpayments, it is clear that plans will accommodate and adopt
more efficient and effective ways to provide care, including
physician networks.
My fifth point then is policies that protect Medicare
beneficiaries, as plans develop narrow networks, are important
at this time.
To elaborate a bit, the most important point relative to
changes is the underlying fact that beneficiaries must always
choose to be covered by, and receive care from, plans rather
than the traditional Medicare program.
We have studies from MedPAC, which indicate that Medicare
beneficiaries in traditional Medicare have very broad access to
physicians and are quite satisfied with that care. One study
found that in spite of the general shortage of primary care
physicians, less than two percent of Medicare beneficiaries in
traditional Medicare reported a major problem finding a primary
care physician.
There is--if you want to view it as--a fallback of a safety
net, and that is where almost 75 percent of the Medicare
beneficiaries are today.
The second point, of course, is that managed care plans
with limited or narrow networks are neither new nor limited to
Medicare.
If we go all the way back to the 1970s, President Nixon and
Senator Kennedy developed the Medicare Assistance Act. That was
all based on Kaiser Permanente, and the entire premise was that
plans would have narrow networks. They could be efficient, they
could manage for care, and as a result, could provide care both
in a less expensive, but also more effective, manner.
We have seen over the years, particularly in the 1990s, on
one hand, a national movement toward plans with narrower
networks followed by a response, and then as the recession
eased, the economy became more robust and employers moved to
much broader networks.
If we then turn to the next point, which is that plans have
been paid more in traditional Medicare over the past, since
2006. We find that Medicare Advantage, the Medicare
Modernization Act, the prescription drug bill in 2003,
implemented in 2006, paid all plans in the Nation more than
costs in fee-for-service in the same county, and, again, the
average was 14 percent, $1,100 in 2009.
The fourth point, of course, is in the ACA, as a general
effort to reduce costs to Medicare and in health care, that
included policies to reduce payments to hospitals and other
providers, these extra additional payments to Medicare
Advantage plans were gradually phased out through the year
2017, and our modeling indicates that by 2017 plans will be
paid an average of 101 percent of costs in the same county.
History and current plan practices suggest that changes by
Medicare Advantage plans to accommodate this gradual phase-down
of these extra payments will likely include some network
narrowing, so I think that is built into the system. I think it
is expected.
I think the most important point of today's hearing is that
since this is a new trend or event in Medicare, there is a need
for new policies, particularly advance notice to beneficiaries.
Particularly, there is something called the advance notice
of changes, which is due on September 30th, that right now only
focuses on benefits and out-of-pocket costs and does not
include any mention of changes in networks, so, if any changes
in networks were included in that September 30th, notice with
the open enrollment period running from October 15th to
December 7th, I think that would give beneficiaries the notice
they need and the time to decide a new plan--for example, in
New Haven, the Aetna plan--or perhaps to shift back to
traditional Medicare.
We might also note if you pick that December 30th date,
then plans would be negotiating with physicians, and I do think
there is both not only the beneficiary point of view but the
physician point of view, but that plans need to engage in that
discussion and negotiation then much earlier in the year in
order to provide the adequate notice to beneficiaries.
I think in conclusion that there is a broad background to
the issue that suggests that network narrowing is reasonable--
it has certainly been historically understood and accepted--but
that as we move from these, again, $1,100 a year extra payments
to plans to something closer to costs in traditional Medicare,
that new policies dealing mostly and foremost with
beneficiaries, but also with physicians, are needed at this
time.
Thank you very much.
Senator Blumenthal. Thank you very much.
Judith Stein.
STATEMENT OF JUDITH STEIN, ESQ.,
FOUNDER AND EXECUTIVE DIRECTOR OF
THE CENTER FOR MEDICARE ADVOCACY
Ms. Stein. Thank you very much for holding this hearing,
Senator Blumenthal, and for coming back home, and the same to
Senator Murphy.
I mentioned to Senator Whitehouse that in addition to
having longstanding alliances with Senators Murphy and
Blumenthal, I have a family of my daughter, son-in-law and
children in Providence, Rhode Island, both of who went to
Brown, so it is really wonderful to have you here today.
Senator Whitehouse. Which we take terribly seriously, so
thank you for mentioning that.
Ms. Stein. As you know, I am the founder and Executive
Director of the Center for Medicare Advocacy, which I founded
in 1986, after having done elder and health care law at
Connecticut Legal Services for 10 years.
The center is a private, nonprofit organization. I think it
is the only organization in the country that can boast it is
based on the quiet corner of Connecticut and has a satellite
office in Washington, D.C. We are in Mansfield, Connecticut,
and we serve the entire state and also hear from people, and
try and advocate as best we can, from those all over the
country.
The center provides education and legal assistance to
advance fair access to Medicare and quality health care for
Medicare beneficiaries throughout the country and Connecticut.
We represent Medicare beneficiaries, respond to over 7,000
calls and e-mails annually, host web sites, webinars, publish a
weekly electronic and quarterly print newsletter, and provide
materials, education and expert support for Connecticut's
CHOICES program.
I am also proudly a member of the executive committee of
the Connecticut Elder Action Network formed and hosted by the
Connecticut Commission on Aging.
We are an unusual organization in the country in that there
are not too many of us who represent Medicare beneficiaries,
and, as a consequence, we also formed and host the National
Medicare Advocates Alliance, where some few dozen of us meet
regularly, and the center provides issue briefs to keep people
abreast of Medicare issues and how to help low and middle-
income, chronically ill, elder and disabled people.
As you know and as the reason for our hearing today, in
2013, UnitedHealthcare jettisoned approximately 2,250 providers
and health care facilities from its Connecticut Medicare
Advantage network--2,250. That is a huge number, particularly
in this small state--about one physician or hospital or nursing
home or other health care provider lost for every 27 people in
the United network in the state and for every 260 Medicare
Connecticut beneficiaries. Neither physicians nor Medicare
patients were given adequate notice of this extraordinary
decision.
As the 2013 Medicare enrollment period and year came to a
close, many older and disabled people enrolled in a
UnitedHealthcare Medicare Advantage plan learned that their
doctors or local hospital would not be available to them in
United's reduced Medicare Advantage network in 2014.
We began to receive calls at the center from people who had
heard this news and were frightened, from our friends at the
Connecticut Medical Society, from our friends in all the
offices of our very fine congressional delegation.
On December 7th, I presented at a meeting held by Rosa
DeLauro, Congresswoman from the Greater New Haven area in
Wallingford. When we had a Q&A, about 25 percent, maybe 30, of
the questions asked by the 150 people on Medicare in the
audience were about their UnitedHealthcare problems.
Many others did not learn until after the new year.
Others will not learn--and this is very important--until
they seek medical care in 2014. Only then will they find that
their doctor or other health care provider is no longer in
their Medicare plan.
In fact, we have been asked why CMS is not hearing about
this problem, and I think the answer is two-fold.
How would people know to contact CMS? Who is and what is
CMS from the point of view of the older and disabled people who
rely on Medicare, and their families? How do they know where to
call? I can tell you 1-800-MEDICARE is not the place.
Secondly, as I indicated and as others have noted, many,
many people will not know about this until they seek medical
assistance into the year. That is when we know, historically,
we find people calling us about Medicare Advantage and Medicare
regularly.
Many people think that Medicare Advantage means that they
have an advantage to their regular Medicare, that it is
something on top of their Medicare.
Under ordinary circumstances, we often get calls after
February or March from people who cannot get health care from
their traditional doctor.
One client of ours and his family learned about the United
network cut only when health care was urgently needed. Susan W.
called the Center for Medicare Advocacy on behalf of her
parents who are both in their 80s.
He had a stroke in 2013, with bleeding in his brain. He was
helicoptered from his local hospital to Yale--New Haven
Hospital due to the complexity of his condition. Now he is
finding in the middle of his care that his medical and
rehabilitation needs are severely limited and further
complicated by the United Medicare Advantage network cuts.
His longtime primary care doctor is no longer in-network,
and I echo the comments of the good doctors--that that is the
relationship that matters to people.
His local hospital is no longer in United's Medicare
Advantage network. He must travel farther to another unknown
hospital, farther from his elderly wife, and find a new doctor
in the midst of getting care for a stroke.
Most importantly, he cannot obtain the nursing care or
rehabilitation he needs at the nursing home closest to his wife
and community since it, too, has been cut from United's
Medicare Advantage plan.
As with many Medicare beneficiaries, Mr. W has long been in
traditional Medicare with supplemental Medigap coverage, but he
switched to United's Medicare Advantage plan in 2011, like my
uncle, because it was less expensive. This worked until he
became ill and United exercised its business prerogative to
severely reduce providers from its Medicare Advantage network.
We know we will hear at the center from many other people
like Mr. W and his daughter as the year proceeds and they need
health care, but their providers, their doctor, their hospital,
their nursing home, in some instances, their home care agency
are found to no longer be in the Medicare Advantage network.
United's health care actions would be bold in the private
health insurance market. They should not be tolerated in the
public Medicare arena. All Medicare Advantage plans, including
United, as Professor Biles just testified, are paid more--
more--by taxpayers than it would cost to provide the same
coverage in traditional Medicare.
While I respect my colleague from AHIP, I have yet, over my
30-plus decades of doing this work, to find one of these plans
regularly providing coordinated care. In fact, not only has my
92-year-old uncle just had terrible problems with his Medicare
Advantage plan, with no coordination of care, but we often find
that, despite the public funding being more than that which
would be necessary for people getting the same care in
traditional Medicare, Medicare Advantage plans often provide
less when people are truly ill.
United owes its Medicare enrollees and providers at least
timely notice and a fair remedy when significant network
reductions like these are planned. It owes its Medicare
enrollees and taxpayers a truly adequate array of providers
when it is receiving public funds--robust payments. It should
not be able to enroll Medicare beneficiaries one year only to
decimate its network the next.
What protections can be put in place?
First, for current United enrollees like Mr. W, who have
been hurt by provider cuts, they should receive help. Further
Congress should act so that such severe network reductions do
not happen in the future. Accordingly, the Center for Medicare
Advocacy recommends the following:
First, to protect current UnitedHealthcare Medicare
Advantage enrollees--and we know this is happening in other
states; New York, Rhode Island, Florida--require
UnitedHealthcare, because it is receiving robust public
funding, to pay the in-network rate on behalf of individuals
such as our client, Mr. W., who cannot find the quality care
they anticipated in-network.
Second, provide a special enrollment period for
UnitedHealthcare Medicare Advantage enrollees so that they can
either change to another Medicare Advantage plan or reenter
traditional Medicare and receive the care from all of the
networks available to them.
Third, require UnitedHealthcare to provide quality
transition services to enrollees such as Mr. W., who are in the
middle of treatment, so that they are--and also, the gentleman
who testified--spoke to the press this morning--so that they
can limit the disruption of their health care. That gentleman
and Mr. W should be able to continue their care with the
providers they know and who have been treating their very
desperate medical situations.
Secondly, how can we protect future Medicare Advantage
enrollees from what we are hearing are expected future network
cuts because the plans will no longer be getting 14 percent
more? That is what ACA did. It started to scale back paying 14
percent more to private plans to be in the system.
Now they can be in the system, but, why should taxpayers
and all Medicare enrollees be paying what was about $150
billion over 10 years additional Medicare Advantage plans than
would be necessary in traditional Medicare?
Require Medicare Advantage plans to provide notice, at
least, I said, 60 days, but the notice that Professor Biles
suggested in the ANOC, the notice that goes out, of change, on
September 30th would also do, when more than a certain
percentage of providers are to be cut from a Medicare Advantage
plan--significant advance notice prior to the beginning of the
enrollment period on October 15th.
Review the definition of an adequate Medicare Advantage
network, to ensure all necessary services are available within
a truly reasonable geographic area. Norwalk, as we know her in
Connecticut, is not truly a reasonable geographic area for a
gentleman with end-stage renal disease to get to the care he
needs when he lives in Bridgeport.
Limit the percentage of each kind of provider a Medicare
Advantage plan may cut from its network.
Require Medicare Advantage plans to pay as if an enrollee's
provider was in-network if the plan is determined by CMS to
have unreasonably reduced its Medicare Advantage providers.
Provide a special enrollment period for Medicare Advantage
enrollees to change Medicare Advantage plans or reenter
traditional Medicare if their plan is determined to have
unreasonably reduced its provider network.
Importantly, level the playing field between the two
Medicare models. For example, include a prescription drug
benefit in traditional Medicare and identify other incentives
in the Medicare Advantage program that entice beneficiaries to
migrate from traditional Medicare to Medicare Advantage, and
these were really put in place in the law that was passed in
2003.
Retain reasonably priced first-dollar Medigap coverage. I
know this will be before you, Senators, in budget cuts that you
will be looking at, and there is this notion that people should
buy Medigap coverage but pay out of pocket before it comes into
effect. This will further push people to Medicare Advantage.
As is the case in Connecticut and some other states, make
it a Federal requirement that Medigap insurance offer
enrollment. Wider access to Medigap will give Medicare
Advantage enrollees more flexibility to return to traditional
Medicare if their Advantage plan no longer meets their
healthcare needs.
In conclusion, Connecticut's older and disabled community,
and our Nation's older and disabled community, deserve better
treatment than they have received from UnitedHealthcare's
Medicare Advantage plan. This kind of behavior should not
happen again, and Medicare beneficiaries caught in this year's
dramatic network cuts should be helped.
Thank you for holding this hearing and for giving me the
opportunity to testify.
Please let me know if the Center for Medicare Advocacy can
do anything further to help.
Senator Blumenthal. Thank you very, very much.
I want to assure, by the way, all the witnesses that your
full statements will be in the record. We are going to make
them a part of the record, without objection.
Let me turn now to Dr. Saffir.
STATEMENT OF MICHAEL SAFFIR, M.D., PHYSIATRIST
AND PRESIDENT, CONNECTICUT STATE MEDICAL SOCIETY
Dr. Saffir. Thank you, Senator Blumenthal and Senator
Whitehouse.
I would like to commend you, sir, on the recommendations
that you have put together. They are very pointed and
successful.
Good morning. I am Dr. Saffir. I am board-certified
physiatrist in pain and sports medicine with the Orthopedic
Specialty Group in Fairfield. I am the President for the
Connecticut State Medical Society, representing more than 6,000
practicing physicians and physicians-in-training in the State.
I received my medical degree from the State University at
Downstate Medical Center and completed my residency, training
and fellowship in neuromuscular diseases and electrodiagnostics
at the Rusk Institute, NY University.
In addition to my practice, I serve on the Connecticut
State Worker's Compensation Commission and Medical Advisory
Committee, where I helped to develop the current attorney-
physician guidelines, insurance payer-physician guidelines,
treatment guidelines and an RVU-based fee schedule.
I am also a member of the Connecticut Prescription
Monitoring Program.
United's abrupt, significant cuts to its Medicare Advantage
program in Connecticut are deeply concerning for both patients
and physicians. United's actions will have significant negative
effects on the physician-patient relationship, the patient
access to care and continuity of care for Medicare
beneficiaries--a vulnerable population with complex medical
needs, including many with chronic conditions and disabilities
that limit mobility.
When UnitedHealthcare decided to drop the physicians in
Connecticut from its Medicare Advantage plan, they did it in a
way that seemed to maximize confusion for patients and doctors.
I would like to let you know that we did ask directly to
United. We actually had some of their senior medical directors
fly into Connecticut to talk to us, and we were told that there
was no cause; it was just a contract; it was not based on
quality.
In fact, the United Medicare Advantage plan has an advisory
panel with physicians. Most of them were unaware that this
process is going forward, and you would think that if you were
making a medically based decision that your advisory panel
would be involved, so many of them stepped down.
The physician terminations letters were sent by bulk mail
in early October. Some received multiple letters indicating
termination. Other doctors had no letter at all but found out
by going to the web site and finding that the names had been
removed from the provider directory.
Physicians who actually received a letter were given no
reason for termination, which made it difficult to appeal.
Phone contact with United staff was challenging, as well as
looking in the online directory.
Both patients and physicians had problems determining
network participation. Terminated physicians were listed as
remaining in-network. Physicians who had not received a letter
were listed as dropped, and many physicians received some
verbal assurance, but no written confirmation was provided,
adding to the confusion.
United made those physician cuts just before the 2013 open
enrollment period began on October 15th, and, as was
highlighted here earlier, patients are required to choose a
plan during that period, and once selected they are locked into
that plan without other options. United failed to notify many
patients of the network changes until mid-November, halfway
through the open enrollment period.
From a physician care perspective, United's actions have
been extremely disruptive. As physicians, we counsel our
patients about health based on the most accurate and up-to-date
clinical information. It is difficult to provide similar
counseling when patients ask questions about whether or not we
would be able to continue treatment and what the continuity of
care would be. There was a lack of accuracy and timeliness of
United's information for them to make decisions.
Many Connecticut State Medical Society, CSMS, members have
shared their stories of patients who were confused and upset by
the changes, because United gave patients no reason for the
network changes, some patients were worried that the doctors
may have done something wrong.
Most recently, United patients have received letters saying
that they can switch to another doctor for their care, but when
the patients call this doctor's office they are told they
cannot be seen or will have to wait weeks or months for an
appointment.
Why? United never bothered to ask those listed doctors if
there was any room left in the patient panels or if they were
able to accept Medicare patients.
Throughout this process, the Center for Medicare and
Medicaid Services, CMS--their lack of oversight and enforcement
has been disappointing. Simply regurgitating that United played
by the rules is not enough.
A common-sense review of travel time and distances
requirements for the elderly and medically vulnerable patients
clearly showed that existing guidelines are unrealistic, even
dangerous.
Following a 90-day notice guideline does not help patients
or physicians when that notice was provided in a disorganized
and incomplete manner. Even more critical, CMS did not seem to
consider the 90-day notice ran through the open enrollment
period. Physicians had to make choices for their 2014 health
care without knowing whether their doctors would be able to
take care of them.
Even more, for complicated patients with multiple medical
conditions, they would have to see different physicians for
these conditions and decide which physicians they would go with
and which plan.
To calculate these decisions were challenging and
difficult. No patient should have to make that choice.
Many of our members have had patients ask whether they
could pay a little extra and stay with the doctor they know and
trust. Patients were horrified to learn that their doctor--it
was not a matter of a few dollars, but since there were no out-
of-network benefits in the Medicare Advantage plans, they would
have to pay the full cost. No patient should have to make that
choice.
This is truly a watershed moment. United's actions have
clearly shown that they place a higher priority on maximizing
profit than maximizing their members' health.
Congress needs to recognize what is occurring here in
Connecticut and across the country, in neighboring states like
Rhode Island, and have patients have better choices when they
are going into the open enrollment period.
I would advocate for that beneficiary notice that Professor
Biles talked about as being an intelligent option.
The solution is simple. Patients' access to care needs to
be protected and maintained for this most vulnerable
population.
United needs to be held accountable for its lack of clarity
and transparency in this process and should demonstrate that
its actions do not jeopardize access to care and actual
provision of care to patients.
CMS should provide a common-sense oversight of United and
not simply accept the insurer's word that the networks are
adequate.
What we would like to see happen is that improvements in
oversight and policing occur and that changes in the law or
regulations that CMS applies to these Medicare Advantage plans
are implemented, and we look forward to working with you on it.
Senator Blumenthal. Thank you.
Dr. Welch.
STATEMENT OF RAYMOND WELCH, M.D., DERMATOLOGIST,
RHODE ISLAND DERMATOLOGY AND LASER MEDICINE
Dr. Welch. Senator Whitehouse, Senator Blumenthal and
Senator Murphy--did he leave?
Senator Blumenthal. Senator Murphy had another commitment
that he had to attend.
Dr. Welch. I see.
Ladies and gentlemen, good afternoon. When I was asked to
speak, I worried that perhaps I would be inadequate to address
the policy issues. Thankfully, I do not have to do that. I
could not possibly have said anything that addresses my
concerns on a nationwide and Federal Medicare scale than what
has been said.
What I can do as a practicing physician is address the
personal side of this. I may add two additional things.
I want to take issue with the idea that the doctors that
were terminated were terminated because of any inadequacy in
their art or science.
Also, I would like to address the idea that
UnitedHealthcare takes care of patients or any insurance
company takes care of patients. I believe it is the physicians
the nurses that do that, and I have never, when I had a concern
about my patients, said, gee, I wonder what an insurance
representative would say?
I challenge any doctor here--have you ever had help from an
insurance company, stopping bleeding, setting a fracture,
treating a cancer, an infection or an inflammatory disease?
Those of you who are not doctors or patients, have you ever
been sick and said, gee, I hope there is an insurance agent who
can help me with this fever?
Senator Whitehouse. For the record, I have never seen an
ambulance in Rhode Island go to an insurance office.
Dr. Welch. Thank you.
In October 2013, we received a letter from UnitedHealth
plan informing me that we had been terminated, effective
February 2014 from the UnitedHealth plan Medicare Advantage
program. We were informed this was by virtue of a contract that
permitted termination without cause with 90 days' notice.
We requested information regarding the metrics that had
been used to decide who was terminated. This request was denied
on the basis that the information was proprietary.
Our appeal was held by a phone conversation with two
UnitedHealth plan medical directors--UnitedHealth plan medical
directors--on December 5th, 2013. Only one question was raised
for discussion--did we feel that we were properly and legally
notified?
We said, no, on the basis of many mistakes that had been in
correspondence that was mailed to us regarding confusing us
with other practices, et cetera.
In any case, our appeal was denied.
UnitedHealth plan has publically stated that their
intention in contracting their Medicare Advantage network, by
eliminating approximately one-third of Rhode Island doctors, is
to improve quality while lowering costs. No data has been
released describing how eliminating some of the finest doctors
in Rhode Island will improve quality. I can only speculate how
contracting the network will lower UnitedHealth's costs by
increasing their profits.
I would like to share with you who my patients are that are
affected by this termination. These are the same generation as
our parents or, as some of us get older, our siblings. They are
the veterans of three wars.
Ninety-four percent of my affected patients are skin cancer
or pre-cancer patients, most of whom have had multiple skin
cancers. One is a heart transplant who has had 164 separate
skin cancers. Another saw four of her doctors, including myself
and a cardiologist, terminated.
One patient, 88 years old and a survivor of 8 skin cancers
in the last 13 years, kept asking, what do I do now, as I
excised yet another squamous cell carcinoma from his chest.
What do I do now?
Some of my patients are simply too old to understand what
is happening to them. I dare say my mother, who is forgetful
but not demented, would struggle with this.
Some clearly did not understand that there was a time
deadline to change their insurance.
Some have told us they assumed that since there was no
rational reason given for my termination that our appeal would
be successful.
Since the termination, the State of Rhode Island and
UnitedHealth plan cut a separate deal for the retirees.
Patients will be allowed to see their terminated doctors as
long as those doctors agree to accept the out-of-network fee
schedule.
UnitedHealth is already our lowest payer and actually, for
their MA plan, discount their payments to doctors. We expect
the out-of-network fee schedule to be even further reduced.
Nonetheless, we will accept the out-of-network fee.
This accounts for about one-half of our UnitedHealth
Medicare Advantage patients.
About one-half of the remaining patients have switched
their insurance to other carriers rather than lose their
doctors, including the patient who stood to lose all four of
her doctors and the heart transplant patient. This passes the
burden of their obviously expensive skin cancer care to the new
insurer and relieves UnitedHealth plan of this cost.
These people have to be taken care of. The cost is the same
no matter who delivers it unless they get inadequate care or
simply fail to find another doctor.
One of our patients switched back to traditional Medicare
A/B with UnitedHealth, Medigap or supplemental insurance. Due
to her skin cancer history, she saw her monthly costs double.
The remaining patients have stayed with UHP. Some are too
old to understand what has happened to them. Some are in
employer-provided retiree plans with no choice and cannot
change.
A review of the dermatology providers UHP lists as
available includes a doctor who is dead, doctors who have
retired, doctors who have left the state, a doctor who is an
internist and has no credentials in dermatology, doctors who
are part-time or not seeing new patients. One of the doctors is
me under an old EIN number and at an address I left 10 years
ago in Providence.
Apparently, the doctor that----
Senator Whitehouse. If you move back, do you think you
would get coverage?
Dr. Welch. I do not know because I think in order to
qualify I have to continue to not see patients.
Most of the private practice dermatologists in Rhode Island
have been terminated, including several of our finest
dermatologists. I will back this statement up if anybody wants
to talk to me later. I will give you names and credentials.
We have been told that UnitedHealth plan is telling
Medicare Advantage patients with no out-of-network coverage,
that if they try three times and cannot find another
dermatologist, then UnitedHealth plan may issue a letter that
allows the patient to continue with us for a given period of
time. This suggests that UnitedHealth plan realizes they do not
have enough dermatologists to cover the loss of terminated
dermatologists.
In summary, UHP has not improved quality by terminating
about one-third of the dermatologists in Rhode Island--and, by
the way, this goes for other specialties as well--particularly
since the availability of qualified replacements in adequate
numbers is questionable.
In fact, being forced to switch from providers such as
myself, who were intimately familiar with their cases, to new
providers may delay care. In the case of my patients, this
means delayed diagnosis and treatment of skin cancer with
increased morbidity, suffering and death for elderly patients.
It would appear that UnitedHealth may lower their own costs
by passing on the costs of care for their more expensive
patients to other insurance carriers or by paying terminated
providers less to care for state retirees or by charging
patients who switch to their supplemental Medicare plan an
increased premium.
On my oath, I have sworn to serve the highest interests of
my patients through the practice of my science and my art and
that I will be an advocate for patients in need and strive for
justice in the care of the sick. This is why I am here today,
and I hope you will join me in defending our elderly patients'
right to the best quality health care.
Thank you for allowing me to speak before this Committee,
and I will try to answer any questions.
Senator Blumenthal. Thank you, Dr. Welch.
I am going to turn first to Senator Whitehouse for his
questions.
Senator Whitehouse. Thank you very much, Chairman
Blumenthal.
Let me thank all of the witnesses for their testimony. I
thought it was a particularly helpful and instructive hearing.
What I extract from it is the conclusion that there are
really three problems going on all at once in the middle of
this.
One is a consumer protection problem, and that is that
people are being subjected to a lot of potentially unfair
treatment, a lot of confusion, a lot of anxiety, problems of
due notice and, of course, the nuisance of having to
accommodate by finding a new provider who may not be the one
you are comfortable with. All of that creates, I think, a
significant consumer protection issue.
Unfortunately, it is a consumer protection problem that
falls most heavily on those who are sickest because it is for
them that the anxiety and that the change will be the greatest.
If you are healthy through all this and you never see a doctor,
it is kind of an abstract problem that you have to face, but,
when you are in the throes of a real illness, this is where it
hurts you.
It is not only a consumer protection problem. It is a
consumer protection problem that has a particular burden for
those who are the most ill and the most vulnerable, so I think
that is a very real concern.
The second problem is the problem of Medicare gamesmanship.
As Ms. Stein mentioned, Medicare Advantage was supposed to
compete head to head with Medicare and that she promised that
it would be less expensive than Medicare when they fought for
the right to compete head to head with Medicare, and by the
time we passed the Affordable Care Act in Congress, they were
14 percent above Medicare. They were being paid a premium when
they said they could do it at a discount.
The Affordable Care Act gets rid of that premium, and that
may enhance the incentive that private carriers have to cherry-
pick the Medicare population, to try to make sure that the
seniors who are golfing every weekend are the ones that they
get and the ones who are in the hospital all the time are the
ones that Medicare gets.
That would be consistent with a recurring problem that we
are seeing in the American corporate world, which is an effort
to privatize profits and socialize costs and use their power in
government to take advantage of the general public for their
own purposes, so you see it in a whole array of different
areas, but it is certainly an acute problem here.
When you see the way this is done, there is at least a flag
of suspicion up that they are doing this in order to dump
expensive patients and to cherry-pick their patient mix and
move expensive patients to Medicare and be able to make more
money off of the population that they reserve.
Until that concern has been rebutted, I think it stands
plainly as a logical concern.
The third is--and Senator Blumenthal, Senator Murphy and I
are all keenly working on this--you know, we have got one of
the most expensive health care systems in the world. Actually,
we have the most expensive health care system in the world by a
margin of about 50 percent above the second most expensive
health care system in the world, which I think right now is
Switzerland.
Doing something about that cost problem is vital. One of
the tools to do something about that cost problem is a well-
managed network, a good network, a high-value network, to use
Ms. Kanwit's phrase.
High-value networks can lower cost. High-value networks are
measured by good outcomes produced by the doctors in the
network, good electronic health record information technology
in the network, good--what would you call it--coordination of
care and handling of patients between doctors and specialists
in the network and providing the very best care and not
unnecessary care and eliminating errors and all that kind of
stuff. All of that is very much worth doing.
There is a final problem here, which is that when an
insurance company chooses to use its network for a bad purpose,
for the purpose of cherry-picking, for the purpose of shoving
expensive patients over to Medicare and keeping the less
expensive ones for itself--which remains, as I said, an
unrebutted proposition here in this hearing because United
would not show up--there is an opportunity cost.
You cannot have a network that is at once designed to dump
your more expensive patients and at the same time is designed
to be the high-value network that should be the goal of our
system. You make a choice. You cannot choose both. It is one or
the other.
When you choose the path that United appears to have
chosen, you are foregoing the path of a responsible high-value
network, and that should be of concern to all of us.
I really do not have any questions so much as to get your
feedback on whether you think I have properly extracted the
three harms that are at issue here, and, in my view, there has
been no testimony to rebut at this point the, I guess, default
proposition that United is behaving in exactly those ways.
Ms. Kanwit. Senator, if I may, I cannot speak to United
where AHIP was not directly involved in that, clearly, but I
would like to talk about two of the issues you raised.
I appreciate your nod to high-value networks because we,
too, at AHIP think that is the way--we think it is the way to
go in the future to get our costs under control and our quality
up.
On the consumer protection problem, our testimony covers,
but there is more information.
CMS has extensive, extensive rules, actually consistent
with some of Ms. Stein's suggestions, which allow for both
adequacy of care and continuity of care--adequacy being that
the network, the MA network, must have providers both in a
geographical sense and in a quantity sense, enough specialists,
enough PCPs, primary care providers, to make access easy for
that particular beneficiary.
There is that adequacy thing and then coupled with the
continuity of care provision, which is also enshrined in our
code of Federal regulations, which CMS administers, talking
about what happens when a beneficiary either cannot get
adequate care within a network. That beneficiary can get out-
of-network care at the in-network price if he or she needs, for
example, a specialized oncologist somewhere, so those issues
are there on the continuity.
If there are network changes, which there will inevitably
be--and CMS, as a matter of fact, wisely, Senator, wants to
keep flexibility so that health plans in the MA space can do
innovations. That is one of the points of MA, but that
flexibility----
Senator Whitehouse. I will concede to you that there are
CMS rules that help protect against some of the worst possible
consumer protections, but I hope you will concede that the
testimony we have heard today shows that for a lot of consumers
this choice by United has been a very anxious-making,
discouraging, inconveniencing and, in some cases, potentially
even care-threatening or compromising occasion.
Ms. Kanwit. I do not have the facts to opine on that, to be
honest with you. I have not followed it, and I just know what
is in the public wheel and the conversation here this morning.
Senator Whitehouse. Okay.
Ms. Kanwit. I do think that there are consumer choices out
there, if I could point out quickly.
For example, there are 12 MA plans, as Professor Biles has
talked about the other consumer choices. There are about 12
other MA plans in the State of Connecticut, and those plans, in
turn, have different benefit designs that a consumer could
choose.
In Rhode Island, there are five MA plans that a consumer
could also go to.
Senator Whitehouse. But you agree that the number of plans
that is available does not cure a problem of short notice or
notice that somebody does not really, you know, experience the
problem until they have signed up and then the problem
detonates and they go to their doctor for the first time six
months later and he says, by the way, I am not in the network
any longer.
I think those are consumer protection problems that are not
solved by the existence of other networks because the person's
choice was not either informed or prepared enough for them in
order to be able to take advantage of the other networks.
Ms. Stein. Senator, I would comment that the issue with
network analysis--unfortunately, there had been a medical
review process where there had been some oversight on the CMS
side in the past, but that was streamlined so that it was
simply a calculation of numbers and a list of names.
As my colleague to my right here pointed out, some of those
names were people who were dead or who moved out of the state
or did not practice correctly.
An insightful analysis is clearly required. Simply just
saying, oh, yes, you know, there are 50 names, and this should
take care of it, and they can handle everything you need; we
have not checked with them; we do not know if they are alive,
is not adequate.
Senator Whitehouse. You would think very much that a high-
value network determination would pick up the deadness of a
doctor.
Ms. Kanwit. Absolutely.
Ms. Stein. Further, it is my understanding that--I think
quite audaciously, if I am correct--the Connecticut
congressional delegation requested a list of the names of the
doctors who were in that work still and those who were not and
was unable to get that information.
Whatever protections there are were clearly inadequate, and
also, I think that this demonstrates perhaps an outlier
activity; that is, it is unusual.
United is--I think, you know, you have got Medicare,
Medicaid and United. United, like, owns healthcare in this
country.
Senator Whitehouse. It is big.
Ms. Stein. It is very dangerous, and it is branded by AARP,
so people go to United.
I had people say to me, well, I am not affected, right,
because I am still with AARP, so, while there are protections,
they clearly have been inadequate.
The definition of an adequate network needs to be reviewed
to make sure it really meets the needs of, first the
beneficiaries and then the physicians.
I can tell you as a breast cancer survivor, if you are in
the midst of getting care, you do not have a fungible
oncologist, a radiation oncologist, an infusion center. These
things are not just going to one Wal-Mart or the other.
I would urge a review of what protections did not work and
what needs to be done to make them work.
Certainly, this cannot be proprietary information. My
office could not get the information, but, how can the United
Connecticut delegation not get this information, and how can
CMS and this Administration, which I know and love, have been
so, I think, repeating--regurgitating, I think the doctor
said--the statements that it meets the rules?
Maybe it did, but it obviously shocks equity and good
conscience, what has happened, which means the rules are
inadequate.
Senator Whitehouse. Well, thank you.
Ms. Stein. We need to level the playing field with
traditional Medicare.
Senator Whitehouse. I am going to very shortly return to
Rhode Island, which, in our neck of the woods, we think is a
long drive from here. We think a drive from Providence to
Newport is a long drive in Rhode Island; so, from Hartford,
back.
Let me take this opportunity to thank Chairman Blumenthal
for holding this hearing. I really, truly do think it has been
instructive.
In addition to the individual cases, I really think that as
we are looking forward at how we fix the health care system and
solve the huge 50 percent extra cost burden that Americans
forced to bear because of the inefficiencies in the cost
system, we are really playing with fire, and our insurance
companies are really playing with fire when they are messing
around with networks.
We had bad network behavior in the bad old HMO days, as you
will remember and as a lot of Rhode Islanders still remember,
when what got you into the network was cutting a special deal
with the insurance company; it had nothing to do with the
patient.
Those were bad old days, and the HMO situation got so bad
that Hollywood made movies about people who were, you know, the
victims of that HMO mentality. Now we have to fight against
that now that we have patient-centered and high-value networks
that need to be done.
If the whole process of pulling physician networks together
gets made disreputable by behavior like this, it is going to be
very hard to take the steps we really need to have to build the
high-value networks that Ms. Kanwit spoke so eloquently about.
There is a real carry-on cost to the health care system,
and I think to all of us, if we do not get this right and if we
do not take the kind of action that Senator Blumenthal is
leading on.
Again, my pleasure to be here, and I will excuse myself and
thank my Connecticut colleagues for their hospitality today.
Senator Blumenthal. Thank you, Senator Whitehouse. We wish
you well on your long drive back to Rhode Island, and thank you
so much for your leadership in this area.
I might just say since we had on this panel two former
attorneys general, as well as two former United States
attorneys, part of this problem strikes me as enforcement. You
know, what Senator Whitehouse referred to as the flag of
suspicion--I think it is more like a cannon burst so far as
possible illegality here is concerned.
After all, a court has found that United Healthcare Group
very probably broke the law and, therefore, has enjoined its
abusive action.
I guess I want to pick up on what Judith Stein emphasized
and others have alluded to--why isn't there better Federal
enforcement in this area?
Most people, as you remarked, do not know what CMS means,
what those initials stand for and what its role or
responsibility is.
There are really two elephants in this room. One is United
Healthcare, and the other is CMS and why it has not taken more
effective action.
I just to confirm what Ms. Stein said. In fact, the
Connecticut delegation sought this information from United
Healthcare, and they were unwilling to provide it.
Let me open that question to all of you, having observed
for a long time Federal enforcement efforts in this area, and
let's turn the light on CMS and other agencies that have a
responsibility.
Dr. Biles. Senator, I think my response would be you are
exactly right, and part of that, of course, is both the number
and the expertise of the individuals in CMS responsible for
managing what is now a $120-plus billion a year program.
I think CMS has, of course, many responsibilities--
hospitals, physicians--across the board. I think in terms of
the numbers and maybe particularly the focus in this area, I
would say, has been lacking.
I know in our case we are interested in data, being
researchers. If we look at the Federal center that provides
data, they have over 100 databases with physicians, hospitals,
prescription drugs. There is not a single database that has
been released on the Medicare Advantage program.
Beyond that, again, just issue by issue--and I think Judy
could comment--they have just been very reluctant to view this
as a kind of Federal program with the sort of transparency that
one would expect in a Federal program.
Ms. Kanwit. Let me also say that, to come to the defense of
CMS, they have had these regulations in place, our plans work
hard to comply with them, Senator, and that the regulations--
that CMS wants the plans to have the flexibility in Medicare
Advantage to make innovations that are not possible in the
Medicare fee-for-service system.
As Senator Whitehouse so eloquently said, we need to move
away from the rigidified--the disjointed--Medicare fee-for-
service system to a much more collaborative and communicative
thing with doctors and hospitals and health plans all working
together to get health care costs down.
Medicare Advantage was supposed to be innovative. It was
supposed to provide benefits. Hence, it is a little more costly
although not always.
Medicare Advantage--actually, Medicare Advantage
beneficiaries in many cases are two percent lower in local
markets--the premiums--than fee-for-service. Two percent lower.
It is not always--and it is not comparing apples to
comparing if you compare fee-for-service, with all due respect
to Ms. Stein, to Medicare Advantage because the Medicare
Advantage has so many more benefits tacked on than the Medicare
fee-for-service.
Senator Blumenthal. I understand your point in the
abstract, and you are right that Senator Whitehouse was very
powerful and eloquent in describing the dynamic of what is
supposed to be occurring.
What we have here is 61,000 patients whose health care was
severely jeopardized. They were put through the emotional
wringer, not to mention the possible detrimental effect to
their health care of, at the very least, opaque and abrupt
treatment by United Healthcare, not only in Connecticut but in
Rhode Island, in Ohio, in Florida, across the country. It was
not an aberrant occurrence here.
In Connecticut, the medical society went to court, and I
joined them, not because I have any legal standing--in fact, I
do not--but I was representing the interests of those patients.
They were representing the doctors.
I think the question can be legitimately asked--where was
CMS?
If CMS felt it did not have the resources or the authority,
don't we need to do something about that enforcement gap?
Obviously, I appreciate your coming to their defense, but I
do not mean that you are personally responsible to answer the
question.
Ms. Kanwit. No, I am speaking generally for the Medicare
Advantage program, Senator, and the advantages it brings to
beneficiaries who are very, very happy generally. Over 90
percent, I mentioned, happiness rates and satisfied rates with
the Medicare Advantage program.
CMS also has come out with statements in this particular
case, the United case--again, I do not speak for United----
Senator Blumenthal. Thank you.
Ms. Kanwit. [continuing]. Talking about the open enrollment
periods, et cetera, one of which we are in the middle of right
now, until February 14th.
Senator Blumenthal. Let me turn to the other witnesses who
may have some response to the question I have raised.
Dr. Saffir. Well, we were going to comment that in terms of
communication, obviously, this is an example where
communication was not well done, so that enhanced value of
communication did not clearly not occur in this situation.
We did try to reach out to United to get answers. I know
that you sent letters. The delegation sent letters.
The attorney general sent letters, and did not get answers.
We did send requests out to CMS and got answers that were
less than satisfactory, and those examples are available, and I
am sure have been submitted as part of the paperwork and
information for this hearing, so that was not satisfactory.
I think that the network analysis needs to have better
review. Like I said, United had a medical advisory panel that
was unaware of this process. They should have been engaged.
When you make a medical adequacy decision, it makes sense to
have doctors involved.
In terms of deciding how to best manage costs, I mean, your
brother published an article in the New England Journal that
talked about these costs and ways to look at it. It cannot be
done working with just bureaucrats since it involves the health
care of patients. You have to have doctors involved.
Ms. Stein. Senator, when Medicare Advantage came into
effect in 2003, there was, in fact, the movement to privatize
Medicare happened. It did not happen with Social Security, but
it happened with Medicare and, to me, shockingly, to the extent
of taxpayers and all Medicare beneficiaries paying a huge
amount more in order to do that.
It is true that the law, I think, needs to be reviewed
because there was a sense that this was not always state
action--and I know you know what I mean by that--but these were
private entities and that, yes, the government was not
intertwined in the way it is with the traditional Medicare
program.
These private entities receive huge amounts, as you know,
of public dollars in a way that is actually partly responsible
for the alleged bankrupting of the Medicare program. United is
not entitled to be a Medicare Advantage plan, and somehow the
American people have misunderstood, have not been heard enough,
of what we are paying, what it is costing us, to have private
insurance plans be part of Medicare.
I suspect that AHIP--I do not know--is as sorry as any of
us that United did what it did because it is creating a huge
problem for the good guys in the system, but they are the
biggest guy, or one of the biggest guys.
We have to make sure that the laws that were put into
effect, largely as a consequence of the law that was passed in
2003 and the regs that followed, which were at the time very
much intended to move people to Medicare Advantage--and that
happened.
It used to be you could move back from traditional Medicare
to Medicare Advantage at this time. This Administration
switched that. The philosophy switched. The implementation and
the regs have not caught up.
If from this hearing we actually could believe that we
would look at the regs to see if they meet this kind of
circumstance, when in fact the clever notion to deal with the
doctors and that removes the sick patients--clever, I say in a
negative way--shows us how much can happen under the current
regs.
We need to make sure that the burden is on the plan to show
that what it has done is to lead to innovation, good
flexibility, true coordination of care and more services, not
$75 toward eyeglasses, not a health club membership, but all
those things that the MA plans and their industry always want
to tell us. The burden should be on the plan to show that value
is really happening.
I can tell you I am one of the few attorneys who represents
Medicare beneficiaries as my career. It has yet to be shown to
me. We were told that in Medicare+Choice, and we have been told
that in Medicare Advantage.
This whole country is paying dearly for what is not good
flexibility. This kind of flexibility is terrible. Medicare
could not get away with it.
What is innovation?
What is coordinated care?
What real more services are being offered?
I think those regs and the burden of showing that needs to
be really reviewed.
Ms. Kanwit. Senator, may I just quickly respond?
Yes, two quick points to Ms. Stein's questions.
On the quality issue, the data out there--and these are not
AHIP's data; they are in respected publications, like Health
Affairs, and we cite them in page three of our testimony--show
the huge quality differences: 17 percent, 20 percent for breast
cancer, diabetes, cardiovascular disease, et cetera, in
Medicare Advantage plans, so there are demonstrable quality
differences.
I also cannot let go unanswered Ms. Stein's impassioned
plea on the alleged motives for the network changes that
United, or anyone else, ever makes in the Medicare Advantage
plan. There is really no incentive for an MA carrier to plan to
cherry-pick, as Senator Whitehouse talked about.
All of it is risk-adjusted. The premiums that the plan gets
are risk-adjusted by CMS, so it does not--the plan can take on
a person with six chronic illnesses versus a person who is
playing golf every day and not be hurt financially.
There is also guaranteed issue in Medicare Advantage.
Anyone can sign up--whether you are healthy as a horse or have
20 chronic diseases.
The point is there is no particular incentive for plans to
do that, so I just want to correct the record on that.
Dr. Welch. May I speak?
Senator Blumenthal. Of course, Dr. Welch.
Dr. Welch. Thank you.
Blue Cross-Blue Shield of Rhode Island has taken on--is it
8,500--8,500 more patients as a result of this, patients who
would not leave their doctors.
As I pointed out, my patients are skin cancer patients.
They need a lot of procedures that are expensive, so those
patients are no longer part of United Health's risk pool.
In addition, they discount the fees that they pay to us
below what Medicare pays.
Now, just so everybody understands, the way that the
Medicare fees are arrived at--there is a panel of doctors
called the RUC panel which makes recommendations across
specialties. These are considered by the government--CMS, I
believe--and then relative values, procedures and services are
assigned that are felt to be fair and equitable.
United Health, to get these efficiencies, discounts those.
They then charge the patient a $40 co-pay, so, for a $45
service, that means the patient pays $40, United Health pays
$5, and the doctor discounts his services.
I think that there is financial incentive here.
Another point that troubles me--you mentioned earlier that
these--there is a phrase I need to have documented. I think the
first word is value. Does anybody remember what that phrase is?
Value? The panels have value?
Ms. Kanwit. High-value provider networks.
Dr. Welch. High-value provider networks, right.
Oh, by the way, thank you for commenting. I admire your
courage.
One of the ways that you said that those high-value would
be determined was through published metrics by a which a doctor
could be determined to be providing good quality care,
something like that. Maybe I am paraphrasing you.
Ms. Kanwit. No, that is accurate.
Dr. Welch. Okay. Well, let's suppose those are there.
I will, to you, lay out my credentials, my 33 years of
experience, my record in taking care of patients, my honors and
awards. I will lay that out.
United Health will not tell us the metrics upon which we
were judged nor will they share their data.
The importance of the data is there are mistakes in here--
bad providers.
By the way, that dead dermatologist was excellent five or
six years.
They make mistakes, but we are not allowed to evaluate the
data.
I am confident that my quality and my skills would equal
any dermatologist practicing in New England. I challenge you to
show otherwise, publically, in any court you want--basketball,
tennis, court of law. Prove it. Okay?
Put your money up. Prove it.
Otherwise, what you have done is you have taken a doctor
who is devoted his career to caring for his patients and
managing skin cancer away from those patients and said, go find
another doctor.
We are not widgets. We are not interchangeable parts. Some
of us specialize in one thing. Some of us are interested in
another. There are reasons that the doctors in Yale
dermatology, by the way--who, I believe, were all terminated--
are ranked among the highest in the world.
Forgive me. I told my wife I would not get passionate.
Senator Blumenthal. Thank you, Dr. Welch.
Dr. Welch. You are welcome, sir.
Senator Blumenthal. Just for the record, because Ms. Stein
mentioned it, I want to say United Health Group is, in fact,
the largest Medicare Advantage provider, at least in
Connecticut, with 43 percent, as I mentioned earlier--61,000.
The next largest is Emblem Health, which has 32 percent and
45,000. The next largest are Aetna with 16 percent; WellCare
Health Plans, five percent; WellPoint, four percent.
United Health Group is not just a small outlier. It is the
major provider in Connecticut, and my guess is a major provider
in those other states where similar kinds of opaque and abrupt
actions have been taken.
Dr. Saffir, did you have something?
Dr. Saffir. You mentioned Emblem Health, and so I had the
opportunity to get together with some of my colleagues in New
York, and I am sure Senator Schumer was also paying attention
to this, but Emblem Health had also considered doing some
network changes, but, given the reaction and the, I guess,
sloppy nature that United incurred, they decided to back off.
It, again, leads me to believe that it was profit-based
because if it was for the good of the patients and they backed
off, then that is a sad mistake, but I think that they realized
this opportunity to make their networks more profitable was not
the time to be taken now.
I think the example that United, as the large payer that it
is, needs to be the example that we look at how we do this
better. I think that is a clear example.
I also say the regular Medicare program, for the amount of
services it delivers, has been shown to be one of the most
efficient in terms of the net medical loss ratio costs. What it
provides versus its overhead expenses--what the CEOs, what the
administrators, what everybody else gets--are not exorbitant in
the regular Medicare system compared to what the salaries might
be for some of the for-profit health plans.
Ms. Stein. Yes, I think that is one of the things I would
like to have. I keep being frustrated that people are not being
told, at least in Connecticut, you can get back to traditional
Medicare and see your physicians--speaking to your constituent.
It is extraordinarily important for them to know that.
Unfortunately, the way this system is stacked towards MA
now, towards private Medicare, it means they have to pick up a
Medigap plan, and in many states they cannot do that. In
Connecticut, happily, we have extra protections, but it is
expensive.
That is part of the reason that we need to look at how can
we level the playing field and then let the private market in
if it can play according to the same rules, but do let people
know that they can go back to traditional Medicare, and in
Connecticut they can get, if they need, a Medigap plan.
Senator Blumenthal. I will just tell you that my office has
been dealing with tens, if not hundreds, of inquiries, trying
to direct them in ways that can reassure them and restore the
health care that they feel they need and deserve, and the kind
of practical work that you are doing with your clients, I
think, has been enormously valuable as well.
Professor?
Dr. Biles. Senator, I was just going to comment. Generally,
as we have said, this is a national issue, and it is one that
is likely to increase.
I think a point that has just been made is that the five
major plans--United, Kaiser, Humana, Blue Cross, WellPoint and
Aetna--have more than 60 percent of the enrollees nationwide,
so here we see a giant, out-of-state insurer, but that is not
unique. That is the pattern primarily across the country.
The lessons from here are not just for Connecticut but for
the Nation.
I think then back to the three points that Senator
Whitehouse made; I think the advance notice by September 30th
would make a big difference and particularly if the plans then
interacted with their physicians earlier than that.
They will complain they do not get their rates until
September, but to use that an excuse not to make this sort of
information available to beneficiaries during the self-
enrollment period, I think, is wrong.
Secondly, CMS has never done very much in this physician
network adequacy area, and, again, to some extent, when they
are overpaid by----
Senator Blumenthal. CMS--just for the record and for the
understanding of everybody who is listening today, CMS actually
has a legal responsibility in that area, does it not?
Dr. Biles. Yes, but this is not an area, I think it is fair
to say, particularly since these very substantial extra
overpayments beginning in 2006 that really focused in this
area.
Again, as the payments ratchet down, this does become an
area in which the individuals at CMS would need to create a
whole new team and people to manage that.
Then I think the third area is this whole risk adjustment
and gaming, and I do think, on one hand, Medicare Advantage has
the best risk adjustment system in the country. On the other
hand, it requires plans to submit data, and you would guess
that plans have resisted submitting more and more data, so I
think that is a third area in which your kind of comments about
CMS's diligence is probably appropriate.
Ms. Kanwit. You know, MA plans, to the professor's
comments, really want to make their beneficiaries happy. They
want to do a good job. They want to follow CMS regulations. I
do not know why they would resist producing data to CMS.
We, at AHIP, just for example, Senator, have a really good
working relationship with CMS. We talk to them all the time
about issues related to this.
They provide incredibly detailed oversight. They just
proposed, actually just last week, additional rules in the Part
C Medicare Advantage space, so they are looking at this with a
fine-tooth comb.
I think the regulation is particularly adequate and what we
are discussing here today is how to move the American health
care system, Senator Whitehouse said, into the 21st Century and
couple cost efficiency and get the quality.
One final point to the professor's comments--the real issue
here is how many choices have, and it does not make any
difference how big a particular plan or how small a particular
plan is in the Medicare Advantage space, say, in Connecticut.
What really counts is consumer choices. There are 12
different MA carriers, MA plans, in Connecticut, and, as I
mentioned, each of those plans have different permutations of
those plans. You can have an HMO plan, a PPO plan, within MA,
so consumers have a lot of different MA choices.
Senator Blumenthal. Well, consumer choice is an
extraordinarily valuable feature until there is bait and
switch, and then consumers may choose but may find that their
choices put them in a position they had not expected.
I think there has been some of that here. Bait and switch
is a fair way to characterize what the effect has been.
In addition to egregiously deficient notice, I think there
has been fairly common agreement--I do not want to speak for
everyone--that the notice here left a lot to be desired.
Remember, after patients were notified, they were also told
that their physicians could appeal, and so they might remain in
the network anyway, and they had a deadline to make decisions.
Nobody can forgive them for being more than a little bit
confused and anxious about the choices that they had under this
system because they had no idea what the consequences of
choices would be in addition to the complexity of the system.
All of the permutations, you know, are a little bit like--I
do not want to impugn another industry, but we all know the
fine print that can often make choices more confusing or
misleading or even deceptive.
I think that this hearing has been enormously valuable, as
Senator Whitehouse said, and your testimony will be a part of
the record.
I am going to close this part of the hearing at this point.
You have been very, very helpful and cooperative.
As long a journey as the Senators may think they had, some
of you have come from much longer distances, and we truly
appreciate it, including Rhode Island, Dr. Welch, and thank you
very much for being here today.
If you want to add anything to your statement, we are going
to keep the record open for a week so that you can feel free to
submit anything else in writing that you would like to do, and
we will make that part of the record also, without any
objection.
Thank you very much.
Ms. Kanwit. Thank you very much.
Ms. Stein. Thank you, Senator.
Senator Blumenthal. We will hear now from Mr. Buccieri if
he is agreeable to doing so.
By the way, while you are switching, I want to give a
particular thanks to the staff of the Committee on Aging, who
has been so helpful and cooperative.
I also want to thank my staff for their excellent work.
Rich and Laurel are here today. I think many of you have spoken
to them and others on my staff who have been so helpful.
Mr. Buccieri, I want to again thank you for being here
today. Both your bravery and your eloquence are very much
appreciated not only by myself but the Committee as a whole,
and I want to really thank you for, again, sharing your story
as you have with my staff and the public and just allow you to
briefly summarize your experience with the Medicare Advantage
plan in which you were enrolled.
Mr. Buccieri. Thank you for the opportunity.
My name is Robert Buccieri, B-u-c-c-i-e-r-i. I have been on
United Healthcare Medicare Advantage plan for almost two years,
and I think that they have done--thus far, it has been a great
policy up until the fall when I started receiving one letter
after another letter after another letter of cancellations--my
nephrologist, the doctors at Yale Transplant, one by one, the
medical group they belong to, as well as the dialysis center in
Norwalk.
It has been an emotional roller coaster, dealing with this,
and I thank you and your staff for helping me along the way. We
are not done, but I think we are making progress.
I just wish that United Healthcare, even with their
responses, was more definite instead of vague. In one letter I
just got yesterday, it said I could see my doctor for 25
minutes from like a 4-month period. I do not even understand
what that means, and it is things like that.
With the dialysis, even it is so many visits, but it is
just difficult because even if I see my doctor and they give
you a 90-day window, if it is not resolved in another 90 days,
I have to do it all over again, and who knows what is going to
happen at that point.
Senator Blumenthal. I gather there was some emergency
condition that required you to seek treatment immediately.
Mr. Buccieri. Yes. Well, my doctors have been very good at
stabilizing, but progression is very slow, and right now I am
in stage five kidney disease, which I guess is called end-stage
renal disease, and I am on the transplant list that, you know,
they have in the hospital, and even just maybe a week ago I
received a phone call from United Healthcare saying that maybe
I could go to Boston or maybe I could go to New York. Who wants
to go to New York or Boston when you have one of the best
hospitals in the State of Connecticut?
It is just things like that.
Senator Blumenthal. These network changes have real-life
practical consequences for your treatment--where it is done, by
whom and so forth.
Mr. Buccieri. Absolutely.
Senator Blumenthal. Has Yale been helpful and cooperative--
Yale-New Haven?
Mr. Buccieri. They have, and you know, people have been
very good about helping, even the reps I have at my health
care, but obviously, they are very limited to what they can do
or what they can say, and I have asked for them to get things
in writing, but even with that, it has not come through.
Senator Blumenthal. Have you sought to contact United
Healthcare?
Mr. Buccieri. On many occasions. As I said, I guess my
nurse liaison or nurse case manager for my health care is very
good, and she has been calling the dialysis center because at
one point she said that they signed a national contract, but my
problem was--or my question was my nephrologist is the medical
director of the dialysis unit. I said, how is that going to
affect, or is that going to affect, the situation?
She was unsure, and she called back and said that some are
changing the doctors and using a different nephrologist.
I have been with this doctor for, I guess, two years, and I
have a very good rapport with him, and I want to continue that.
I do not really want to start a new doctor.
When they asked me that maybe I could go to New York or
Boston, I said that is a possibility, but then you begin again
at the bottom of the list, and here we go, you know, waiting
another couple of years or who knows how long.
Senator Blumenthal. You begin at the bottom of the list in
terms of eligibility for the transplant.
Mr. Buccieri. Yes.
Senator Blumenthal. You begin with a new doctor whom you do
not know, and you have to go to a place that is distant from
where you live.
Mr. Buccieri. Yes.
Senator Blumenthal. All of those factors make it very, very
difficult and different to receive health care under those
terms.
Mr. Buccieri. That is true.
Senator Blumenthal. Is there anything else that you would
like to add?
I know that my staff has been very much engaged in seeking
to help you, and we appreciate your cooperation in that effort,
too.
Mr. Buccieri. I appreciate the help, and your staff has
been very helpful--Grady, in particular.
I think the main thing--obviously, I would like to get the
whole thing solved and get my doctor back, but if in fact they
cannot, I would like to get some sort of notification in
writing saying what I can do because even if they say I can see
my doctor, how do I go to the doctor and tell them that I want
to see someone out of network, but do not worry; they are going
to get paid for it?
You know, I think it is going to be very difficult.
Senator Blumenthal. Well, thank you again for being here.
Grady Keefe of my office and I are going to continue
working with you and fighting for you.
Again, we are very, very grateful--the whole Committee is--
for your attendance today and your participation. Thank you so
much.
Mr. Buccieri. Thank you for this opportunity and the help
you have provided.
Senator Blumenthal. Thank you.
I am going to close the hearing.
As I mentioned earlier, the record will stay open for one
week in case any Committee members have questions for the
witnesses or if the witnesses have additional submissions.
With that, this hearing is adjourned. Thank you.
[Whereupon, at 3:47 p.m., the Committee was adjourned.]
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APPENDIX
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Prepared Witness Statements
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Statements for the Record
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